The demand on Australian EDs has increased by an average of 4.2% each year while the cancer incidence rate has doubled since 1991. Many patients with cancer present to EDs but may be better managed using alternative healthcare models.

2. Emergency Department
Bypass for Cancer Patients?
Meredith Oatley CNC Oncology RNSH
Professor Stephen Clarke, Director Cancer Services NSLHD
Professor Margaret Fry, Director Nursing Research NSLHD
Lesley Mullen CNE Emergency RNSH
Royal North Shore Hospital
Northern Sydney Local Health District
October 2015

3. AIM
The primary aim of the study was to
explore the prevalence and
characteristics of adult cancer patients
presenting to the ED Royal North
Shore Hospital NSW
Australia

4. Study Objectives
• To identify pt characteristics for admission to the ED
- how many and how often in a 12 month period
• Preconception that the majority of cancer patients
were presenting after hours
• To identify gaps in care in look at new models of care

5. Emergency Department Demand
• Australian Hospital ED’s had 6.5 million patient
presentations in 2012
• 4.2% increase in presentations from 2007 to 2012
• RNSH had the highest % increase in patient
presentation from 2012-2013

6. Methods
• Retrospective e-Medical audit over 12 months
(n=290) (1st January 2012 – 31st December 2012 )
• Data retrieved included patient demographics and
clinical information
• Data were analyzed using excel
• Descriptive, comparative and correlational statistical
analysis was performed using SPSS

7. Ethics
Ethical approval was obtained
from the Northern Sydney Local Health
District Human Research Ethics
Committee

8. Results
Total Cancer patients presenting to ED in 2012:
1,110 out of 62,919
(2.4%)
Medical Record Audit:
290
Oncology (n= 255: 87.9%) Haematology (n=35: 12%)

9. Results
Medical Record Audit: 290
Demographics:
Average age 65.3 years
Female n=146 (50.3%)
Male n=144 (49.7%)
Mode of Transport
Private vehicle n=183 (63.0%)
Ambulance n=99 (34.1%)

10. Most common symptoms at
presentation
Fever n=54 (19%)
Abdominal Pain n=34 (12%)
Shortness of Breathn=32 (11%)
Abnormal Test Findings n=29 (10%)

11. Clinical Information
Triage Categories Arrival By Day & Time
TC 1 n=6 (2.07%) Monday-Friday n=231(80%)
TC 2 n=94 (32.4%) Sat & Sun n=59(20%)
TC 3 n=131 (45.2%) 8.00-17.00 n=173(60%)
TC 4 n=54 (18.62%) 1701-07.59 n=117(40%)
TC 5 n=5 (1.72%)
Majority of patients presented during business hours

12. Results
Antibiotics:
Average time was 120 mins (SD +/- 85.5)
Oncology n=125.6 (87.36)
Haematology n=88.3 (69.21)
CVAD Access:
•CVAD documented: n=27 (9%)
•Accessed in ED: n=15 (56%)
•Cannula + CVAD: n= 6 (22%)

13. Chemotherapy
Within one week of presentation n=96 (33%)
Triage as Cat 2 n=68 (71%)
Documented cytotoxic PPE n= 33 (34%)
Within one day of presentation n=44 (15%)
Presented Monday-Friday n=34 (77%)
Radiotherapy:
Overall n=41 (14%)
Within 4 weeks n=15 (36%)

14. Presentation Frequency
Average Presentation Rate over 12 months
3.4 times n=162 (56%)
Presented once n= 70 (24%)
Presented twice n= 58 (20%)
Presented > 3 times n= 162 (56%)
Group
Presented 2-7 times n= 201 (69%)
Presented 8-15 times n= 19 (1%)

15. Length of Stay + Mortality
Length of stay 7 days
Length of Stay in ED
Mean 5:06 hours (SD +/- 15minutes)
Died within 12 months of ED presentation:
105 (36%)

16. Disposition
Admitted to hospital n=271 (93%)
Discharged n=9 (3%)
Transferred to Critical Care n=5 (2%)
Transferred to another hospital n=3 (1%)
Died in ED n=2 (1%)

17. Research Summary
 The study demonstrated that cancer patients visiting
ED had a high acuity, are allocated high triage codes
and that the majority of patients were admitted (93%)
and presented during business hours Monday to Friday
 36% of patients had died within 12 months of ED
presentation
 This study results suggests that an ED presentation for
cancer patients could be a high predictor of mortality
rate

18. Major Implications
• Patients attend in working hours contrary to
our expectations
• Almost all are admitted – suggests they are
either sick or ED staff are unconfident to send
home
• Their processing and treatment takes too
long, although pain management was good
• Care is not provided by specialist staff
• Can we introduce different models of care?

19. Proposed Models of Care for ED Bypass
• Acute assessment unit model (AAU) – to
review low triage categories
• Cancer Telephone Nurse Led Help Line for
rapid assessment and triage
• Cancer Nurse practitioner lead urgent review
service in cancer treatment clinics – support
on call for ED/AAU/Cancer care/helpline to
provide specialist clinical expertise

20. What we have done – AAU bypass
• AAU bypass ED for low category triage codes
• Model Implemented - Dec 2014
• Total of 101 oncology/haematology patients
admitted into the AAU in the nine months of
the model being implemented
• 9% reduction in front door ED admissions

21. • Telephone helpline - Point of contact to provide
telephone advice, assessment and triage by oncology
nurse specialists to support patients and provide the
best care
• Urgent review service – Nurse Practitioner on-call for
cancer clinic/AAU/ED/helpline, prevent front door
admissions, reduce ED congestion provide
specialised care
What we would like to do

22. Future Research
Future Australian research needs to explore the role of help
lines, social media and community support for cancer patients
Further research into end of life care and ED utilisation is
needed to explore new palliative care models to assist patients
in the terminal phase of illness

23. Questions & Discussion

24. References
 Ahn, S., Lee, S., Lim, K. & Lee, J. 2012. Emergency department cancer unit and management
of oncologic emergencies: experience in Asian Medical Center. Support Care Cancer, 20,
2205-10.
 Australian Institute of Health and Welfare 2012-2013, Australian hospital statistics 2012-13:
emergency department care, no 52, Canberra: AIHW.
 Australian Institute of Health and Welfare 2014, Australian hospital statistics 2012-13,
Australian Government, viewed 10 June 2014
<http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129547000>
 Bureau of Health Information, 2014. Emergency Department utilisation by people with
cancer, Ministry of Health
 Dellinger, R.P., Levy, M., Rhodes, A., Annane, D., Gerlach, H., Opal, S., Sevransky, J.,
Sprung, C., Douglas, I., Jaeschke, R., Osborn, T., Nunnally, M., Townsend, S., Reinhart, K.,
Kleinpell, R., Angus, D., Deutschman, C., Machado, F., Rubenfeld, G., Webb, S., Beale, R.,
Vincent, J.-L. & Moreno, R. 2013. Surviving Sepsis Campaign: International Guidelines for
Management of Severe Sepsis and Septic Shock, 2012. Intensive Care Medicine, 39, 165-228.

25. References
• Leak, A., Mayer, D.K., Wyss, A., Travers, D. & Waller, A. 2013. Why do cancer
patients die in the emergency department?: an analysis of 283 deaths in NC EDs.
Am J Hosp Palliat Care, 30, 178-82.
• Naurois, J., Novitzky-Basso, I., Gill, M., Marti Marti, F., Culklen, H., Royler, F.
& ESMO Guidelines Working Group 2010. Management of febrile neutropenia:
ESMO Clincial Practice Guidelines. Annals of Oncology, 21, 252-6.
• Royal College of Physicians, 2013. Acute care toolkit 7: acute oncology medical
unit October 2013, Royal College of Physicians, London
• Sadik, M., Ozlem, K., Huseyin, M., AliAyberk, B., Ahmet, S. & Ozgur, O. 2014.
Attributes of cancer patients admitted to the emergency department in one year.
World J Emerg Med, 5, 85-90.
• WHO 2014, Cancer, World health organization, viewed 11 June 2014
<http://www.who.int/mediacentre/factsheets/fs297/en/>.